1114935939 NPI number — PROFESSIONAL PHYSICIAN SERVICES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114935939 NPI number — PROFESSIONAL PHYSICIAN SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL PHYSICIAN SERVICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114935939
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7845 OAKWOOD RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
GLEN BURNIE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21061-4280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-760-1010
Provider Business Mailing Address Fax Number:
410-787-1056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7845 OAKWOOD RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
GLEN BURNIE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21061-4280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-760-1010
Provider Business Practice Location Address Fax Number:
410-787-1056
Provider Enumeration Date:
08/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MUNESES
Authorized Official First Name:
JUDE
Authorized Official Middle Name:
CABATINGAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
410-760-1010

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LZ85PR . This is a "BLUE SHIELD OF MD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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